Mental illness is a significant public health issue in Singapore. The 2010 Singapore Mental Health Study (SMHS) found that 1 in 17 suffered from major depressive disorder, and 1 in 33 from obsessive-compulsive disorder (IMH, 2011), with the latter surpassing the US and Europe (The Straits Times, 2016). There is considerable delay in help-seeking behaviors, with most not seeking help altogether (IMH, 2011). Existing apps in Singapore (Vulcan Post, 2014) seek to promote self-help through private thought diaries, mood trackers, and goal-setting. However, such individual coping strategies can generate withdrawal with worse consequences due to self-stigma (Link, Mirotznik, & Cullen, 1991).
For self-help to be more effective, the pervasive cultural stigma attached to mental health patients must be tackled. This can be achieved by leveraging on the appeal of meditative activities. Despite its Eastern origin, 8% and 10.1% of surveyed Americans used meditation and yoga/taichi/qigong respectively for their health needs (Clarke, Black, Stussman, Barnes, & Nahin, 2015). Studies have consistently found that mindfulness-based therapy can reduce depression, anxiety and stress tolerance (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010; Marchand, 2012). While meditation apps exist, they remain individual-level interventions. This constitutes a missed opportunity to reduce mental illness stigma and provide this marginalized group with more beneficial coping strategies.
Proposed Public Health App: MindfulSG
I propose the creation of a companion app to ActiveSG that promotes mental health. Like its counterpart, MindfulSG serves as a platform for the booking of facilities and programmes. Instead of physical activities like swimming, the app can promote activities like meditation, yoga, taichi, qigong, and even music. Putting mental health on par with physical health efforts will serve as a great recourse for those with chronic physical illness – 50.6% of diagnosed mental illness cases (IMH, 2011) – already marginalized by current healthy lifestyle efforts. An additional buddy/family function will allow Singaporeans to join these sessions together via invitations. By inserting the topic of mindfulness into the national and private conversations, mental help-seeking can be more normalized. This will encourage closet patients to adopt socially-integrated coping strategies and even seek clinical help.
As such activities require guidance, regulations are needed for credibility. Practitioners will need to register to be certified as ‘experts’ by Singapore Sports Council or Institute of Mental Health, before they can conduct sessions. Many should be drawn by the opportunity of a national platform, which can ensure a critical supply of programmes. A ratings system of participant satisfaction can be used to ensure continued quality in sessions. This mirrors those in doctor apps (Healthgrades, 2014), but without the complication of inaccurate appraisals due to poor medical knowledge, as these sessions are precisely aimed at improving subjective moods. These checks will alleviate concerns of subpar sessions, encouraging more Singaporeans to participate. With high participation rates, cultural sensitivity towards mental health issues can be more effectively promoted.
However, those with depression or anxiety may be inhibited from social activities, at least initially. To promote participation, sample meditations should be included in the app. These represent an immediate self-help tool for at-risk individuals to utilize in their free time, during commute or before sleep. They should be of varying durations to cater to situational and attentional differences. Community progress trackers, showing total number of plays of the recordings, can generate a sense of solidarity and normalcy in using mental self-help tools. Health statistics and patient stories can be included, with the message that mental illnesses are often not purely biological, but are often triggered by stressful life events (Andrews & Wilding, 2004; Strohschein, 2005). This not only reduces self-blame, but also allows caregivers to better empathize with their kins. Stronger social support is associated with better well-being through both promotive and protective mechanisms (Cohen & Willis, 1985). By elevating public consciousness, both the individual and social functions of the app can become effective as early interventions.
Challenges and Solutions to Implementing MindfulSG
The main objectives of MindfulSG are 1) promoting help-seeking behaviors beyond clinical settings, and 2) reducing stigma towards mental health patients. Both are interrelated and must be pursued in tandem. The app’s success can be directly indicated by its signup, audio playback, and social participation rates, along with the user ratings. For representativeness, national epidemiological studies (SMHS) need to be conducted regularly. The app can also be used as part of clinical therapy programmes for diagnosed patients, whose progress can be easily monitored.
Given the app’s goals, the biggest challenge is achieving scale on a national level. First, there are practical barriers. Good practitioners with established followers may not be incentivized to register. To be seen as a key publicity platform, the best-rated practitioners can be rewarded with in-app profile features and even free Mediacorp ads, which can periodically attract new users. High provision is vital as travel distance is likely a key determinant of participation. To increase convenience, practitioners should be allowed to conduct such activities in a multitude of unfixed locations, while the public can indicate their preferred regions to direct locational supply. Cost is also a significant barrier for sceptics of the app’s efficacy. The government can, like with ActiveSG, offer free $100 credit for a start. Discounts can also be given to those who attend sessions with buddies or family members.
Second, there are lifestyle barriers. The high incidence of mental illnesses in Singapore can be attributed to stressful school and work lives, with most occurring by age 26 (IMH, 2011). It is thus pertinent to intervene within institutions. A new feature for institutions to declare interest will be useful. These sessions can be integrated within Physical Education classes in schools and morning fitness programmes in work organizations. Rewards – e.g. extra sports funding – can be given to schools with highest usage of the sample meditations. This is feasible since student registration is only an additional step from the NRIC details required to use this national app. The extension into institutions will ensure the app’s resilience to fluctuations in demand and normalize mindfulness as a way of life to the benefit of all, not just mental health sufferers.
References
Andrews, B., & Wilding, J. M. (2004). The relation of depression and anxiety to life‐stress and achievement in students. British Journal of Psychology, 95(4), 509-521.
Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based stress reduction therapy on mental health of adults with a chronic medical disease: A meta-analysis. Journal of Psychosomatic Research, 68(6), 539-544.
Clarke, T. C., Black, L. I., Stussman, B. J., Barnes, P. M., & Nahin, R. L. (2015). Trends in the use of complementary health approaches among adults: United States, 2002–2012. National Health Statistics Reports, (79), 1.
Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98(2), 310-357.
Healthgrades. (2014). Healthgrades iPhone App. Retrieved November 10, 2016 from https://www.healthgrades.com/blog/healthgrades-iphone-app-making-healthcare-personal.
Institute of Mental Health (IMH). (2011, November 18). Latest study sheds light on the state of mental health in Singapore. Retrieved November 8, 2016, from https://www.imh.com.sg/uploadedFiles/Newsroom/News_Releases/SMHS%20news%20release.pdf.
Link, B. G., Mirotznik, J., & Cullen, F. T. (1991). The effectiveness of stigma coping orientations: can negative consequences of mental illness labeling be avoided? Journal of Health and Social Behavior, 32(3), 302-320.
Marchand, W. R. (2012). Mindfulness-Based Stress Reduction, Mindfulness-Based Cognitive Therapy, and Zen Meditation for Depression, Anxiety, Pain, and Psychological Distress. Journal of Psychiatric Practice, 18(4), 233-252.
Strohschein, L. (2005). Parental divorce and child mental health trajectories. Journal of Marriage and Family, 67(5), 1286-1300.
The Straits Times. (2016, January 3). Calls for greater support as more in Singapore suffer anxiety illness. Retrieved November 8, 2016, from http://www.straitstimes.com/singapore/health/call-for-greater-support-as-more-in-singapore-suffer-anxiety-illness.
Vulcan Post. (2014). 5 Singapore Apps To Help Keep Your Health In Check. Retrieved November 10, 2016, from https://vulcanpost.com/18606/5-singapore-apps-health-in-check/.